Association Between Multimodal Analgesia Administration and Perioperative Opioid Requirements in Patients Undergoing Head and Neck Surgery With Free Flap Reconstruction

Abstract

IMPORTANCEThe opioid epidemic has reignited interest in opioid-sparing strategies in managing pain. However, few studies have focused on opioid use during perioperative care in patients undergoing head and neck surgery with free flap reconstruction.OBJECTIVES To examine the association between multimodal analgesia (MMA) administration and perioperative opioid requirements in patients undergoing head and neck surgery with free flap reconstruction and to investigate whether MMA alters the duration of stay in the postanesthesia care unit (PACU). DESIGN, SETTING, AND PARTICIPANTSIn this retrospective case-control study, data were collected between April 1, 2016, and December 31, 2017. The study was conducted at a single cancer center in the United States. Participants were 357 patients 18 years or older scheduled for head and neck surgery with free flap reconstruction.EXPOSURES Patients in the treatment group received oral celecoxib, gabapentin, and/or tramadol hydrochloride before surgery. Control group patients did not receive any of these medications. MAIN OUTCOMES AND MEASURESThe amount of opioid administered in the operating room and in the PACU was converted to morphine equivalent daily dose (MEDD) for comparison between the 2 groups. The duration of stay in the PACU was based on the start time and end time of PACU care recorded by nurses in the PACU. RESULTS Intotal, 149 patients (mean [SD] age, 60.3 [13.7] years; 104 [69.8%] men) were included in the treatment group, and 208 patients (mean [SD] age, 64.2 [13.6] years; 146 [70.2%] men) were included in the control group. The mean (SD) MEDD of opioid given during surgery was 51.7 (19.8) in the treatment group and 67.9 (24.7) in the control group, for a difference in the means (treatment vs control) of −16.17 (95% CI, −20.81 to −11.52). In the PACU, the mean (SD) MEDD of opioid given was 11.7 (13.3) in the treatment group and 14.9 (15.7) in the control group, for a difference in the means (treatment vs control) of −3.22 (95% CI, −6.40 to −0.03). The MMA treatment remained largely associated with reduced amount of opioid given during surgery, in the PACU, and both combined after controlling for other important factors.CONCLUSIONS AND RELEVANCE This case-control study found that the patients who received MMA before head and neck surgery with free flap reconstruction required less opioid medication. The treatment group also had shorter duration of stay in the PACU compared with the control group.

Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review

“…Nine of 10 studies 16-24 (n = 1151) used an 11-point numerical scale to assess pain, including the visual analog scale (VAS) (6 studies, 16,20-24 n = 774) and the Defense & Veterans Pain Rating Scale (DVPRS) (1 study, 17 n = 65) ( Table 4 ). There was wide variation in subjective pain outcomes among the included studies.…”

“…After duplicate removal and screening by abstract and title, 66 full-text articles were assessed with 10 studies ( 2RCTs, 1 open-label trial, 7 matched cohort studies) meeting inclusion criteria (Table 1). [15][16][17][18][19][20][21][22][23][24] A total of 1253 patients were included with 594 patients in the MMA group and 659 in the non-MMA group. Using weighted averages, the overall population was 62.0 6 5.4 years old and 68.6% male (MMA, 61.0 6 6.0 years, 69.2% male; non-MMA, 62.9 6 4.6 years, 68.0% male) with no difference between the 2 groups.…”

“…Eight of 10 studies [15][16][17][18][19]21,23,24 (n = 1025) observed a significant decrease in overall postoperative narcotic usage (Table 3). Nine studies [15][16][17][18][19][20][21][22][23] used morphine milligram equivalents (MMEs) to assess additional narcotic usage while Zhang et al 24 reported additional use of sufentanyl. Other significantly improved functional metrics included sedation score, antiemetic use at postoperative day (POD) 1, and time from bed to chair.…”

Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients

“…There are few publications studying the use of MMA protocols in head and neck cancer surgery with free flap reconstruction. Vu et al demonstrated reduced opioid use intra-operatively and in the post-anesthesia care unit (PACU) when patients were administered pre-operative oral celecoxib, gabapentin, and/or tramadol hydrochloride [ 13 ]. This study, however, did not investigate opioid use after the patients were discharged from PACU.…”

“…MMA reduces opioid consumption and may reduce opioid-related side effects [ 11 , 12 ]. A recent study by Vu et al showed MMA was effective in reducing opioid consumption in the post-anesthesia care unit (PACU) in patients undergoing major head and neck surgery [ 13 ]. Many current MMA regimens for head and neck cancer surgery patients recommend the combined use of non-steroidal anti-inflammatories (NSAIDs) and/or COX-inhibitors, and paracetamol.…”